Frail Intervention Therapy Team (FITT): Integration of Early
Interdisciplinary Assessment in the Emergency Department (ED)
Ciara O’Reilly1, Paul Maloney 2, Yvonne O’Riordan 2, Paul Bernard 2, Eleanor Alexander1 , Aoife Molloy3, Martina Boyle4, Sinead Cunneen5 , Ciara Reddy6 . Beaumont
Hospital, 1:Physiotherapy, 2:Occupational Therapy, 3:Medical Social Work, 4:Speech and Language Therapy, 5:Dietetics, 6:Pharmacy.
Introduction:
The presentation of older adults to the ED with acute illness is
often complicated by various markers of frailty. It is essential that
services for older adults are integrated and should encompass the
following three key principles:
1.
Access to a medical diagnosis
2.
Access to a comprehensive multi-disciplinary assessment
3.
Access to the most appropriate treatment in the right
setting and at the right time
In response to the need to respond to these key principles, a
clinical redesign process began in Beaumont Hospital in
September 2015, from which the Frail Intervention Therapy Team
(FITT) was born.
The FIT Team is a group of Health and Social Care Professionals
(HSCPs) dedicated to identifying the frail in ED, providing early
comprehensive multidisciplinary assessment and thereby
ensuring the person’s HSCP needs are met in as timely a manner
as possible.
•Dietetics
ED Doctor
•Pharmacy
ED nurse
•Physiotherapy
Figure 3: An example of one PSDA cycle
• New Common Screening
Tool implemented:
currently on Draft 10
Act
Study
Plan
• Implement
Standardised
paperwork for all
patients identified as
FRAIL Positive
Do
• Cover sheet altered for
handover to ward staff
• Discipline specific
documentation altered to
streamline assessment
• All patients over 75
identified as FRAIL
positive had CST
completed by a
Physiotherapist or
Occupational therapist
Results:
Over a twelve month period from Sept. 2015 - 2016,
approximately 6000 patients were triaged for frailty and of those,
75% presented with frailty markers. Comparing Quarter 1 of 2015
to Quarter 1 2016 an 11.6% increase in ED presentations for ≥75
year olds was observed. Significantly, there was a 57% increase in
all ≥ 75 year olds being discharged over the same timeframe
under the 9 hour Patient Experience Time target, with 59% of this
group being discharged home.
Figure 4: ED Presentations > 75 years Q1 2015 vs Q1 2016
2500
•Occupational Therapy
•Speech and Language
Therapy
Admitting teams
2000
20
Geriatricians
•Social Work
33
1500
206 more
presentations
+11.6%
523
474
95+
85 to 94
1000
75 to 84
1293
Methodology:
Quality Improvement methodology underpinned the change
process. The PDSA tool facilitated change in action.
Figure 1: Driver diagram for ED FITT project
Aims
Primary Driver
Secondary Driver
Figure
1: Driver
diagram
for EDfrail
FITT
project• Introduce HSCP triage of frail elderly patients using
•To
identify
100%
of Identify
elderly
the ‘Think Frail’ tool
frail patients,≥75
patients
• Develop communication systems to ensure early
years who present
referral flagging from point of triage
to the E.D. during
• Ensure patients identified as frail receive early
Establish
care
core working hours
specialist comprehensive assessment using a
pathways
• To provide frail
patients with
comprehensive
MDT assessment
within 24 hours of
presentation to ED
common screening tool (CST)
• Implement efficient processes to support
communication between teams
• Commence therapy in the ED/AMAU
Foster an ethos of
‘every hour
counts’, for frail
patients in ED
within the wider
heath care team.
• Develop an infrastructure to support local testing of
the ‘frailty triage tool’
• Align work with other relevant work streams
including the Specialist Geriatric Ward and Day
Hospital.
• Optimise opportunities for spread and sustainability
both at local departmental level and organisational
level.
• Ensure reliable communication across clinical
teams of at risk patients
• Develop a shared language within the organisation
Figure 2: Patient Journey through ED
Triage
• Nursing triage
• HSCP Frailty Triage, presenting complaint, social history, ED medical decision
HSCP
• Triage Therapist identifies potential discharge destination, flags HSCP
required
ED Therapy
Teams
Core ward
therapy
• Discharge team - home with appropriate supports/ possible day hospital
review OR admission assessment team
• Transferred to a ward, handover care of the patient to the ward based
therapist.
1438
500
0
2015
2016
Discussion:
Nationally our elderly population is growing, evident in the
numbers presenting to our EDs. The FIT Team undertook to
identify and subsequently provide early intervention to ≥75 year
old frail adults, thereby improving their hospital experience and
overall outcomes. The success of this service to date is largely
accounted for by the integration of the interdisciplinary team.
Beaumont Hospital is committed to the objectives of the National
Clinical Programme for Older People (NCPOP). Through a
continual of PDSA cycle of quality improvements, the FITT service
is now embedded into practice within the Beaumont Hospital ED.
•A Plan
•Resources
•Focused Staff
•Clinical Leadership
and Support
•Senior Management
Team Support
•Strong Teamwork
•No Blame Culture
•QI Methodology
•Shared Vision
Enablers of Sustainability:
Staff: Rotation of staff
through ED to foster a
culture of every hour counts
Process: Standardising
processes e.g. figure 3
Organisation Alignment:
with National Clinical Care
Programme and Beaumont
Hospital’s Improvement
Plan
The FIT team acknowledge the contribution of multiple staff, both within the
HSCP Departments and the wider hospital to this clinical redesign process.